|

Received: 5 May 2022    Accepted: 6 May 2022

DOI: 10.1111/clr.13955

CONSENSUS REPORT

Effect of peri-­implant mucosal thickness on esthetic outcomes

and the efficacy of soft tissue augmentation procedures:
Consensus report of group 2 of the SEPA/DGI/OF workshop

Ronald E. Jung1  | Kathrin Becker2  | Stefan P. Bienz1  | Christer Dahlin3  |

Nikos Donos4  | Christian Hammächer5 | Gerhard Iglhaut6,7  | Antonio Liñares8  |
Alberto  Ortiz-­Vigón9  | Nerea Sanchez9,10  | Ignacio Sanz-­Sánchez9,10  |
Daniel S. Thoma1  | Cristina Valles11 | Dietmar Weng12  | José Nart11
1
Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
2
Department of Orthodontics, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
3
Department of Biomaterials, Institute for Surgical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
4
Centre for Oral Clinical Research, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
5
Private Practice, Aachen, Germany
6
Department of Oral and Craniomaxillofacial Surgery, Translational Implantology, Center for Dental Medicine, University Medical Center of Freiburg, Freiburg,
Germany
7
Private Center of Oral Surgery, Memmingen, Germany
8
Periodontology Unit, Faculty of Odontology, University of Santiago de Compostela & Medical-­Surgical Dentistry Research Group, Health Research Institute of
Santiago de Compostela, Santiago de Compostela, Spain
9
Section of Graduate Periodontology, University Complutense, Madrid, Spain
10
ETEP (Etiology and Therapy of Periodontal and Peri-­implant Diseases) Research Group, School of Dentistry, University Complutense, Madrid, Spain
11
Department of Periodontology, Universitat Internacional de Catalunya, Barcelona, Spain
12
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-­Albrechts University, Kiel, Germany

Correspondence
Ronald E. Jung, Clinic of Reconstructive
Dentistry, Center of Dental Medicine,
University of Zurich, Plattenstrasse 11,
CH-­8 032 Zurich, Switzerland.
Email: ronald.jung@zzm.uzh.ch
Abstract
Objectives: The aim of this study was to comprehensively assess the literature in
terms of the effect of peri-­implant mucosal thickness on esthetic outcomes and the
efficacy of soft tissue augmentation procedures to increase the mucosal thickness
with autogenous grafts or soft tissue substitutes.
Material and methods: Two systematic reviews (SR) were performed prior to the
consensus meeting to assess the following questions. Review 1, focused question: In
systemically healthy patients with an implant-­supported fixed prosthesis, what is the
influence of thin as compared to thick peri-­implant mucosa on esthetic outcomes?
Review 2, focused question 1: In systemically healthy humans with at least one dental
implant (immediate or staged implant), what is the efficacy of connective tissue graft
(CTG), as compared to absence of a soft tissue grafting procedure, in terms of gain in

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. Clinical Oral Implants Research published by John Wiley & Sons Ltd.

|
100   wileyonlinelibrary.com/journal/clr
 Clin Oral Impl Res. 2022;33(Suppl. 23):100–108.
JUNG et al. |
      101

peri-­implant soft tissue thickness (STT) reported by randomized controlled clinical tri-
als (RCTs) or controlled clinical trials (CCTs)? Review 2, focused question 2: In systemi-
cally healthy humans with at least one dental implant (immediate or staged implant),
what is the efficacy of CTG, as compared to soft tissue substitutes, in terms of gain in
peri-­implant STT reported by RCTs or CCTs? The outcomes of the two SRs, the con-
sensus statements, the clinical implications, and the research recommendations were
discussed and subsequently approved at the consensus meeting during the group and
plenary sessions.
Conclusions: There was a tendency of superior esthetic outcomes in the presence of
a thick mucosa. The connective tissue graft remains the standard of care in terms of
increasing mucosa thickness.

KEYWORDS
color measurement, esthetic outcomes, implant dentistry, papilla index, patient-­reported
outcome measures, peri-­implant mucosa, peri-­implant soft tissue, pink esthetic score

1  |  I NTRO D U C TI O N
The mucosal thickness is a parameter, which has been frequently
investigated in conjunction with biological and esthetic outcomes at
implant sites (Chan et al., 2019; Kan et al., 2011; Mailoa et al., 2018;
Schwarz et al., 2021).
Different methods of assessments, indices, parameters, and
patient-­reported outcome measures have been proposed to quan-
tify and qualify esthetic outcomes (Chang et al.,  1999; Fürhauser
et al.,  2005; Jemt,  1999). Moreover, esthetic outcomes were sug-
gested to be associated with either a thin or thick mucosal thick-
ness/phenotype (Garabetyan et al.,  2019; Tatum et al.,  2020). A
threshold value of 2 mm of buccal mucosal thickness was primarily
introduced by (pre-­)clinical studies assessing the color differences
of implant prostheses on the level of the mucosa (Jung et al., 2008;
Lops et al., 2017; Sala et al., 2017). Consequently, it was proposed
to use a categorization of <2 mm (thin) and ≥2 mm (thick) in future
research (Avila-­Ortiz et al., 2020).
Besides the mucosa thickness, a variety of studies have in-
troduced the term of peri-­implant phenotype to characterize the
peri-­implant dimensions. As per definition, the term peri-­implant
phenotype encompasses the peri-­implant mucosa width, the mucosa
thickness, the supracrestal tissue height, and the peri-­implant bone
thickness (Avila-­Ortiz et al., 2020). Like the periodontal phenotype,
the peri-­implant phenotype is site-­specific and has frequently been
reported as thin or thick (De Rouck et al.,  2009; Kan et al.,  2003;
Müller et al., 2000).
Various soft tissue augmentation procedures were described
to increase the mucosal thickness around dental implants apply-
ing autogenous gingival grafts or soft tissue substitutes (Langer &
Calagna, 1980; Schneider et al., 2011; Thoma et al., 2016). The im-
pact of different soft tissue grafting techniques and biomaterials on
increasing in mucosal thickness and esthetic outcomes is still a sub-
ject of debate (Avila-­Ortiz et al., 2022).
Therefore, the task of the group was (i) to evaluate the influence
of a thin as compared to a thick mucosa on esthetic outcomes at
dental implants and (ii) to assess the efficacy of a connective tissue
graft versus the absence of treatment or versus a soft tissue substi-
tute in increasing the peri-­implant mucosal thickness and improving
the esthetic outcomes.
2  |  WO R K S H O P D I S C U S S I O N A N D
CO N S E N S U S
2.1  |  Systematic Review (SR) 1: The influence of
thin as compared to thick peri-­implant soft tissues on
esthetic outcomes. A SR and meta-­analysis (Bienz et
al., 2021).
This SR aimed to evaluate the influence of the thickness of the buc-
cal mucosa around implants on esthetic outcomes. Clinical stud-
ies with ≥10 patients with dental implants, published until August
2020, were searched. Studies reporting the thickness of the buc-
cal mucosa by means of a measurement in mm (with an endodontic
file or ultrasound device) or by means of a phenotype determina-
tion (shimmering of a periodontal probe) and an esthetic outcome
were included. Esthetic outcomes encompassed the Pink Esthetic
Score (PES; Fürhauser et al., 2005), papillae index (Jemt, 1999), pres-
ence of papillae (yes/no; Romeo et al.,  2008), papillae height (mm;
Chang et al., 1999), color measurements (spectrophotometric meas-
urements; Jung et al.,  2007), and buccal marginal mucosal levels
(mm). An additional search for relevant articles published between
September 2020 and January 31, 2022, was performed.
PECO question: “In systematically healthy patients with an
implant-­supported fixed restoration (P), what is the influence of thin
(E) as compared to thick (C) peri-­implant soft tissues on esthetic out-
comes (O)?”
 |
102      JUNG et al.
Results: Thirty-­n ine articles reporting on 34 unique patient
populations were included. Out of the included unique studies,
nine were randomized controlled trials, one was a controlled clin-
ical trial (CCT), 10 were prospective cohort studies, eight were
cross-­s ectional studies, and six were retrospective cohort stud-
ies. The risk of bias was overall high. 1508 patients and 1606
sites were part of the analysis. The mean difference in the PES
after the follow-­u p was not significantly different between thin
(<2.0 mm) or thick soft tissues (≥2.0 mm) or phenotypes (12 stud-
ies; MD = 0.15; [95% CI =  −0.24; 0.53]; p  =  .46). An increased
mean mucosal thickness was associated with an increased papilla
index (five studies; MD = 0.5; [95% CI = 0.1; 0.3]; p = .002) and an
increase in papilla presence (five studies; OR = 1.6; [95% CI = 1.0;
2.3]; p  =  .03). Thin soft tissues were associated with increased
recession, −0.62 mm (four studies; [95% CI  =  −1.06; −0.18];
p  =  .006). Patient-­reported outcome measures (patient satisfac-
tion) were in favor of thick soft tissues −2.33 (six studies; [95%
CI = −4.70; 0.04]; p = .05).
Conclusions: Within the limitations of various study designs, var-
ious soft tissue measurements, and time points, it can be concluded
that an increased soft tissue thickness (STT) at implant sites was as-
sociated with more favorable esthetic outcomes.
2.1.1  |  Consensus statements (SR 1)
1. What are the most frequently reported esthetic outcomes in
implant dentistry?
Based on 34 studies (nine randomized clinical trials (RCTs), one
controlled clinical trial, 10 prospective cohort studies, eight cross-­
sectional studies and six retrospective cohort studies) with 1508 pa-
tients and 1606 implants, the following esthetic outcome measures
were described:
a. Pink Esthetic Score (PES, Score 0–­14; Fürhauser et al., 2005)
b. Papilla index (Score 0–­4; Jemt, 1999)
c. Presence of papillae (yes/no; Romeo et al., 2008)
d. Papilla height (mm; Chang et al., 1999)
e. Color measurements (Spectrophotometry; Jung et al., 2007)
2. What is the most frequent and comprehensive esthetic index/
score/method in implant dentistry?
In clinical practice, several factors should be combined for de-
scribing comprehensively the esthetic outcomes around dental im-
plants. Based on the available evidence provided in this SR, the group
suggested that PES is a comprehensive index for measuring esthetic
outcomes following different single implant placement and loading
protocols.
3. What is the influence of the mucosal phenotype on PES?
Based on 11 studies (two RCTs, three prospective case series,
three cross-­sectional studies, and three retrospective cohort studies)
including 663 patients and 688 implants, it was demonstrated that
PES was not significantly different between thin and thick phenotype
(MD = 0.15; [95% CI = −0.24; 0.53]) during the different stages follow-
ing prosthetic treatment and follow-­up time points (12–­106 months).
4. Does peri-­implant mucosal phenotype/thickness influence the
change in esthetic outcomes over time?
Based on three studies (two prospective case series and one retro-
spective case series) including 97 patients and 97 implants, there was
a tendency (p = .05) for a higher increase in the PES for patients with
a thick phenotype/thickness (MD = 0.72; [95% CI = 0.00; 1.43]) with
follow-­up periods ranging from 12 to 74 months.
5. What is the association between the buccal mucosal thickness
and the presence/height of a papilla (with presence of an ad-
jacent tooth)?
Based on five studies (four RCTs and one prospective case se-
ries) including 125 patients and 143 implants, it was shown that
each additional mm of mucosal thickness was associated with an
increase in papilla index (MD = 0.21; [95% CI = 0.08; 0.34]) and an
increase in papilla presence (OR 1.55; [95% CI = 1.03; 2.31]) with
follow-­ups ranging from 12 to 86 months. However, there are sev-
eral factors that should be considered in regard to papilla measure-
ments which include the surgical placement of the implant, the type
of implant placed in the area, and the relevant temporary and final
prosthesis.
6. What is the association between the buccal mucosal thickness
and the buccal marginal mucosal level?
Based on four studies (one RCT, two prospective case series, one
retrospective case series), a statistically significant reduction in buc-
cal marginal mucosal level (BSTD; buccal soft tissue dehiscence) was
found for patients with a thin phenotype (two studies)/reduced muco-
sal thickness (two studies; MD = −0.62; [95% CI = −1.06; −0.18]) after
follow-­ups ranging from 12 months to 8 years.
7. What are the patient-­reported outcomes related to the thick-
ness of the peri-­implant mucosa/phenotype?
Based on six studies (one RCT, two prospective case series, two
cross-­sectional, one retrospective case series) including 272 patients
and 281 implants, there was a tendency (p = .05) in favor of thick mu-
cosa/phenotype for higher patient satisfaction after follow-­up periods
ranging from 12 months to 8.9 years (MD  =  −2.33; [95% CI  =  −4.70;
0.04]).
JUNG et al.
8. What is the association between the buccal mucosal phenotype/
thickness and the color match of the peri-­implant marginal
mucosa with the marginal gingiva?
Based on nine studies (five RCTs, one CCT, two cross-­sectional
studies, and one retrospective cohort study) with 317 patients and 359
implants, no significant difference in color match was seen between
thick and thin mucosa/phenotype (MD: 0.66; [95% CI = −0.16; 1.47]).
Eight studies measured the mucosal thickness and one determined the
phenotype. The mean follow-­up time ranged between final prosthesis
insertion and 5.1 years.
The factors that may influence the color match include the various
material characteristics (color/material/design) of the abutment/pros-
thesis and the position of the implant as well as surgical techniques
(flap design/scarring).
9. Which assessment method (phenotype determination or mucosal
thickness in mm) may be used as an indicator for final esthetic
outcomes?
The most frequently reported methods to assess the mucosal
thickness are the phenotype categorization (e.g., transparency of the
periodontal probe) and the quantitative evaluation in millimeters (end-
odontic file, ultrasonic device, caliper, cast analysis, etc.). Eleven, out
of twelve studies assessing the PES, used the phenotype to categorize
the groups. Therefore, there is a lack of information on how the as-
sessment method may be used as an indicator for esthetic outcomes.
However, the incremental increase in the mean mucosal thickness
in mm was associated with the presence of a papilla (OR 1.55; [95%
CI = 1.03; 2.31]), as well as with higher papilla index scores (MD = 0.21;
[95% CI = 0.08; 0.34]).
2.1.2  |  Implications for clinical practice (SR 1)
• In areas of high esthetic risk/demands, clinicians should be aware
of the possible impact of the mucosal thickness regarding esthetic
outcomes.
• In areas of high esthetic risk/demands, a mucosal assessment
should be part of the initial treatment planning and the related
risk factor analysis.
• In patients with a thin mucosa, it is the responsibility of the cli-
nician to provide specific information in relation to the possible
long-­term esthetic risks.
• The clinician should be aware that different implant placement
and loading procedures may be associated with different esthetic-­
related challenges.
2.1.3  |  Implications for future research (SR 1)
• Researchers should design adequately powered trials where the
esthetic outcomes are the primary outcome.
|
      103
• As PES is used for single implants, the group recommends that an
index for the esthetic assessment of multiple implants should be
developed.
• It is recommended to assess the validity of the incremental
increase of mucosal thickness in mm as a prognostic indicator
for esthetic outcomes of dental implants. The group suggested
that comparison of different non-­invasive methodologies of
assessing mucosal thickness or phenotype determination is
imperative.
• Future studies in implant dentistry should take into consideration
the perceptions of the patients in relation to long-­term esthetic
outcomes.
2.2 | SR 2: Efficacy of soft tissue augmentation
procedures on tissue thickening around dental
implants: a SR and meta-­analysis (Valles et
al., 2022).
The purpose of the present SR was to critically assess the evidence
on the efficacy of soft tissue augmentation procedures around
dental implants in terms of gain in peri-­implant STT and esthetic
outcomes. Clinical studies including ≥5 patients per group with a
follow-­up of ≥3  months after grafting, reporting on peri-­implant
soft tissue thickening (primary outcome), the level of the mucosal
margin, the width of the keratinized mucosa, esthetics, clinical, and
radiographic parameters as well as patient-­reported outcome meas-
ures (PROMs; secondary outcomes) published until July 2020 were
searched.
Focused question: The following focused questions were
developed:
PICOS question 1: In systemically healthy patients with
at least one dental implant (immediate or staged im-
plant), what is the efficacy of a connective tissue graft
(CTG), as compared to the absence of a soft tissue
grafting procedure, in terms of gain in peri-­implant
STT reported by randomized controlled clinical trials
(RCTs) or CCTs?
PICOS question 2: In systemically healthy humans with
at least one dental implant (immediate or staged im-
plant), what is the efficacy of a CTG, as compared to
soft tissue substitutes, in terms of gain in peri-­implant
STT reported by RCTs or CCTs?
Results: Eight trials were included to answer the first focused
question and eight to answer the second one, providing data for 254
and 192 patients, respectively. For the first focused question, a sta-
tistically significant weighted mean difference (WMD) of 0.64 mm
(95% CI [0.16; 1.13]; p = .01) in STT was found in favor of the grafted
group (n = 8 studies). The level of the mucosal margin was signifi-
cantly more coronal (n = 4; WMD = 0.50 mm; 95% CI [0.19; 0.80];
 |
104      JUNG et al.
p < .001) applying a CTG compared with the absence of treatment.
For the second focused question, a significantly greater gain in STT
was found for CTGs compared with soft tissue substitutes (n  = 8;
WMD  =  0.51 mm; 95% CI [0.28; 0.75]; p < .001). Furthermore, the
use of CTGs resulted in a significantly higher pink esthetic score
(PES; n = 3; WMD = 1.02; 95% CI [0.29; 1.74]; p = .01) and a more
coronal level of the mucosal margin (n = 2; WMD = 0.50 mm) com-
pared with soft tissue substitutes. No statistically significant differ-
ences between groups were observed for PROMs, except for pain
medication intake, which was significantly higher when using CTGs
compared with soft tissue substitutes (n = 2; WMD = 1.68 tablets
within the first week; 95% CI [1.30; 2.07]; p < .001).
Conclusions: Soft tissue augmentation procedures are efficacious
in soft tissue thickening and, in particular, CTG demonstrated a sig-
nificantly greater STT gain when compared to the absence of treat-
ment or soft tissue substitutes.
2.2.1  |  Consensus statements (SR 2)
1. What were the clinical indications of increasing the peri-­implant
mucosal thickness?
Based on 14 investigations (12 RCTs and two CCTs), the reported
clinical indications to increase the mucosal thickness included as
follows: compensation of the loss of bone volume after immedi-
ate implant placement (Jiang et al.,  2020; Migliorati et al.,  2015;
van Nimwegen et al.,  2018), prevention of buccal peri-­implant
soft tissue dehiscences (Frizzera et al.,  2019; Jiang et al.,  2020),
to increase the soft tissue dimensions (Cairo et al., 2017; Hutton
et al.,  2018; Kamal et al.,  2020; Papapetros et al.,  2019; Puzio
et al.,  2018; Schmitt et al.,  2021; Thoma et al.,  2016; Ustaoğlu
et al., 2020; Wiesner et al., 2010), and improvement of esthetics
(Hosseini et al., 2020).
According to the expert's opinion, peri-­implant mucosal thick-
ness could also be increased to improve the emergence profile of
implant-­supported prosthesis and, hence, self-­performed oral hy-
giene measures.
2. What is the standard of care to increase the peri-­implant mucosal
thickness?
Based on 14 studies (12 RCTs and two CCTs), CTG in com-
bination with a bilaminar approach (i.e., coronally advanced flap
(Cairo et al.,  2017; Hutton et al.,  2018; Papapetros et al.,  2019;
Ustaoğlu et al., 2020; Wiesner et al., 2010), tunnel technique (Jiang
et al.,  2020; Migliorati et al.,  2015), and envelope flap or pouch
(Frizzera et al., 2019; Hosseini et al., 2020; Kamal et al., 2020; Puzio
et al., 2018; Schmitt et al., 2021; Thoma et al., 2016; van Nimwegen
et al.,  2018) is the most effective treatment to increase the peri-­
implant mucosal thickness.
3. When could clinicians consider using a soft tissue substitute to
increase the peri-­implant mucosal thickness?
Clinicians should be aware that mechanical and physico-­chemical
properties as well as the origin of the products available on the mar-
ket differ. The use of soft tissue substitutes appears to be less ef-
fective for most of the outcome measures related to the esthetics
(i.e., STT changes, level of the soft tissue margin, and PES) compared
with the use of a CTG. In specific clinical situations, soft tissue sub-
stitutes may serve as an alternative to CTGs. This includes patient's
preference, reducing surgical time and medication intake, single sites
with minor deficiencies, and limited availability of autogenous tissue.
4. What is the effect of applying a CTG to increase the peri-­
implant mucosal thickness compared with the absence of
treatment?
Based on eight studies (seven RCTs and one CCT), apply-
ing a CTG results in a significantly thicker peri-­implant mucosa
(WMD = 0.64 mm; 95% CI [0.16; 1.13]; p = .01) compared with the
absence of treatment.
5. What is the effect of applying a CTG to increase the peri-­implant
mucosal thickness compared with the use of a soft tissue
substitute?
Based on eight investigations (seven RCTs and one CCT), ap-
plying a CTG results in a significantly thicker peri-­implant mucosa
(WMD  =  0.51 mm; 95% CI [0.28; 0.75]; p < .001) compared with a
soft tissue substitute.
6. What is the impact of the timing (simultaneous with or post-­implant
placement) of the soft tissue augmentation procedure on changes
in peri-­implant mucosal thickness?
Based on eight studies (seven RCTs and one CCT) for compar-
isons between CTG vs. no graft and eight studies (seven RCTs and
one CCT) for comparisons between CTG vs. soft tissue substitutes,
the timing of soft tissue grafting did not significantly influence the
increase in mucosal thickness.
7. What is the stability of the increased peri-­implant mucosal thick-
ness with a CTG compared with the absence of treatment?
According to the present SR, the follow-­up (i.e., ≥1 year or <1 year)
did not influence the outcomes of STT changes between CTG and the
control group (no graft; p = .55). In this context, the WMD for increase
in mucosal thickness was 0.96 mm (95% CI [−0.35; 2.28]; p = .15) and
0.54 mm (95% CI [0.01; 1.07]; p  =  .05), in favor of CTG, for studies
with a follow-­up <1  year (2 RCTs) and ≥1  year (5 RCTs and 1 CCT),
respectively.
JUNG et al.
8. What is the stability of the peri-­
implant mucosal thickness aug-
mented with a CTG compared with a soft tissue substitute?
Differences between CTG and soft tissue substitutes were af-
fected by the length of follow-­up (p = .03) and the differences between
the groups were more pronounced in those studies with ≥1  year of
follow-­up, in favor of a CTG. In this sense, the WMD for increase in mu-
cosal thickness was 0.37 mm (95% CI [0.18; 0.55]; p < .01) and 0.79 mm
(95% CI [0.46; 1.11]; p < .01), in favor of CTG, for studies with a fol-
low-­up <1  year (four RCTs and one CCT) and ≥1  year (three RCTs),
respectively.
9. What is the effect of increasing the mucosal thickness applying
a CTG compared with the absence of treatment on esthetics as
assessed by the pink esthetic score (PES)?
Based on three RCTs, an increase in mucosal thickness applying
a CTG did not result in a significant esthetic benefit (WMD = 1.18;
95% CI [−0.56; 2.91]; p = .18) after 12 months following soft tissue
grafting.
10. What is the effect of increasing the mucosal thickness when ap-
plying a CTG compared with soft tissue substitutes on
esthetics?
Based on three RCTs, PES scores were significantly higher for
CTG compared with soft tissue substitutes (WMD  = 1.02; 95% CI
[0.29; 1.74]; p = .01) at short-­and medium-­term follow-­up.
11. What is the influence of increasing the mucosal thickness when
applying a CTG versus the absence of treatment on the level/posi-
tion of the mucosal margin?
Based on four investigations (three RCTs and one CCT), applying
a CTG results in a significantly more coronal position of the mucosal
margin compared with the absence of treatment (WMD = 0.50 mm;
95% CI [0.19; 0.80]; p < .001).
12. What is the influence of increasing the mucosal thickness when
applying a CTG versus soft tissue substitutes on the level/position
of the mucosal margin?
Based on two RCTs, applying a CTG results in a significantly
more coronal position of the mucosal margin compared with soft
tissue substitutes (WMD = 0.50 mm; 95% CI [0.10; 0.89]; p = .014).
13. What is the influence of increasing the mucosal thickness on the
height of the papillae?
Based on 2 RCTs with a 1-­ and 2-­year follow-­up, respectively,
the height of the papillae was not influenced by the treatment when
comparing a CTG vs. no graft (mesial papilla: WMD  =  −0.10 mm;
95% CI [−0.54; 0.34]; p = .66/distal papilla: WMD = 0.02 mm; 95%
|
      105
CI [−0.32; 0.37]; p = .89]). On the contrary, two studies comparing a
CTG with soft tissue substitutes assessed changes in mesial and dis-
tal papillary height (Frizzera et al., 2019; Thoma et al., 2020) and no
statistically significant differences between groups were observed.
However, due to the different methodologies used in these studies,
a meta-­analysis could not be performed.
14. Is evidence available on the long-­term esthetic outcomes (PES) of
implants after increasing the peri-­implant mucosal thickness?
Based on the present SR, there is no available scientific literature
with a follow-­up >5 years on the long-­term esthetic outcomes of im-
plants after increasing the peri-­implant mucosal thickness.
15. What is the difference between an autogenous connective tissue
graft and the absence of treatment in terms of increasing the
peri-­implant keratinized mucosa?
Based on three studies (two RCTs and one CCT), the changes
in peri-­implant keratinized mucosa width were not signifi-
cantly different between the CTG and the absence of treatment
(WMD  =  0.38 mm; 95% CI [−0.24; 0.98]; p  =  .23). Applying a CTG
in combination with a bilaminar approach did not increase the peri-­
implant keratinized mucosa width, especially in those sites with
≥2 mm of keratinized tissue width at baseline (Lin et al., 2018).
16. What is the difference between autogenous connective tissue grafts
and soft tissue substitutes in terms of increasing the peri-­implant
keratinized mucosa width?
Based on five RCTs, the changes in the peri-­implant keratinized
mucosa width were not significantly different between the two
treatment modalities (WMD  =  −0.09 mm; 95% CI [−0.40; 0.22];
p = .57). Minor changes in keratinized mucosa width were observed
after increasing the peri-­implant mucosal thickness with CTG or soft
tissue substitutes in combination with a bilaminar approach.
17. Can peri-­implant soft tissue thickening improve clinical and radio-
graphic parameters related to peri-­
implant health (i.e., probing
depth, plaque indices, bleeding indices, and marginal bone level)?
Based on a varying number of included RCTs and CCTs reporting
on the different parameters, an increase in mucosal thickness does
not improve clinical (probing depth, plaque indices, and bleeding in-
dices) and radiographic outcomes (marginal bone level).
18. Do soft tissue substitutes reduce patient morbidity (i.e., pain per-
ception and medication intake) when compared to CTGs?
Based on three RCTs, pain perception (i.e., measured using a
VAS) was not significantly different between CTGs and soft tissue
substitutes (WMD = 12.13; 95% CI [−2.88; 27.15]; p = .11). Based on
two RCTs, medication intake (i.e., tablets within the first week) was
 |
106      JUNG et al.
significantly higher in patients receiving a CTG compared with pa-
tients receiving soft tissue substitutes (WMD = 1.68; 95% CI [1.30;
2.07]; p < .001).
19. Do soft tissue substitutes improve the overall patient satisfaction
when compared to CTGs?
Based on two RCTs, patient satisfaction was not significantly
different between the two treatment modalities (WMD  =  −0.49;
95% CI [−7.82; 6.85]; p = .90 on VAS 0–­100). Both treatment options
achieved a high patient satisfaction.
20. Does the use of soft tissues substitutes reduce the surgical time
as compared to the use of CTGs?
Based on two RCTs, the surgical time was not significantly differ-
ent between the two treatment modalities (WMD = 5.54 min; 95%
CI [−17.56; 28.65]; p = .64).
According to the expert's opinion, the use of soft tissue substi-
tutes may reduce the surgical time compared with the use of CTGs,
mostly after the soft tissue substitutes preparation and handling
learning curve.
2.2.2  |  Implications for clinical practice (SR 2)
Indications in general: STT may be important to compensate the
loss of bone volume after immediate implant placement, to pre-
vent a peri-­implant soft tissue dehiscence, to increase the soft
tissue dimensions, to improve esthetics, and to improve the implant-­
supported prosthesis emergence profile and cleansability, especially
when treating thin peri-­implant phenotypes.
• In such clinical situations, the use of a CTG in a bilaminar manner
is the most indicated treatment modality to increase the peri-­
implant mucosal thickness.
• Applying a CTG also results in a more coronal position of the peri-­
implant mucosal margin and enhanced esthetics, especially in the
long-­term, but might be associated with a higher patient mor-
bidity and a longer surgical time in comparison with soft tissue
substitutes.
• CTG donor sites can include the palatal premolar area, the pos-
terior palate, or the tuberosity. Dense lamina propria located
immediately beneath the epithelium is the preferred tissue to be
harvested.
• The oral exposure of the CTG underneath the flap may result in
an increase in keratinized mucosa width but unpleasant esthetic
results.
• Although the use of soft tissue substitutes is less effective than a
CTG in increasing STT, they may serve as an alternative in specific
clinical situations such as patient's preference, reducing surgical
time and medication intake, single sites with minor deficiencies,
and limited availability of autogenous tissue.
• Clinicians should be aware that the soft tissue substitutes
available on the market vary in terms of origin and design,
physico-­chemical properties, and scientific documentation.
Consequently, these materials are proposed for specific clinical
interventions (i.e., gain of keratinized tissue and gain of mucosal
thickness).
2.2.3  |  Implications for future research (SR 2)
Researchers are advised to:
• study the influence of the initial mucosa thickness, and the thick-
ness and origin of the graft on the increase of the thickness of the
peri-­implant mucosa
• assess longitudinal and long-­term data (>5 years) on the changes
in the mucosa thickness and the level of the peri-­implant mucosal
margin, following procedures to increase the mucosa thickness
• investigate the influence of procedures to increase the mucosa
thickness on peri-­implant health (probing depth, bleeding on prob-
ing, radiographic marginal bone levels) in the long-­term (>5 years)
• assess the effectiveness of soft tissue substitutes compared with
the absence of treatment in the long-­term (>5 years)
• develop new biomaterials and scaffolds as soft tissue substitutes
providing stable space maintenance with the aim of increasing the
thickness of the mucosa.
• develop different methods of assessment using digital technolo-
gies to evaluate changes of the peri-­implant mucosal thickness
AU T H O R C O N T R I B U T I O N
All authors contributed to the interpretation of the data of the two
systematic reviews, developed the questions and provided the an-
swers as well as recommendations. R.J. and J.N. led the writing, and
all authors reviewed the manuscript.
C O N FL I C T O F I N T E R E S T
The authors report no conflict of interest related to the manuscript.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Ronald E. Jung  https://orcid.org/0000-0003-2055-1320
Kathrin Becker  https://orcid.org/0000-0003-1936-4683
Stefan P. Bienz  https://orcid.org/0000-0002-8562-1580
Christer Dahlin  https://orcid.org/0000-0001-7131-5577
Nikos Donos  https://orcid.org/0000-0002-4117-9073
Gerhard Iglhaut  https://orcid.org/0000-0002-9874-7238
Antonio Liñares  https://orcid.org/0000-0003-1611-5884
Alberto Ortiz-­Vigón  https://orcid.org/0000-0002-1863-5907
JUNG et al.
Nerea Sanchez  https://orcid.org/0000-0003-1681-428X
Ignacio Sanz-­Sánchez  https://orcid.org/0000-0002-3698-4772
Daniel S. Thoma  https://orcid.org/0000-0002-1764-7447
Dietmar Weng  https://orcid.org/0000-0001-5799-6361
José Nart  https://orcid.org/0000-0002-2363-4992
REFERENCES
Avila-­Ortiz, G., Couso-­Q ueiruga, E., Pirc, M., Chambrone, L., & Thoma,
D. S. (2022). Outcome measures and methods of assessment of soft
tissue augmentation interventions in the context of dental implant
therapy: A systematic review of clinical studies published in the last
10 years. Clinical Oral Implants Research. https://doi.org/10.1111/
clr.13927 [Online ahead of print]
Avila-­Ortiz, G., Gonzalez-­Martin, O., Couso-­Q ueiruga, E., & Wang, H.
L. (2020). The peri-­implant phenotype. Journal of Periodontology,
91(3), 283–­288. https://doi.org/10.1002/JPER.19-­0566
Bienz, S. P., Pirc, M., Papageorgiou, S. N., Jung, R. E., & Thoma, D. S.
(2021). The influence of thin ascompared to thick peri-­implantsoft
tissues on aesthetic outcomes. A systematic review and meta-­
analysis. Clinical Oral Implants Research, 56–­71. https://doi.
org/10.1111/clr.13789
Cairo, F., Barbato, L., Tonelli, P., Batalocco, G., Pagavino, G., & Nieri, M.
(2017). Xenogeneic collagen matrix versus connective tissue graft
for buccal soft tissue augmentation at implant site. A randomized,
controlled clinical trial. Journal of Clinical Periodontology, 44(7), 769–­
776. https://doi.org/10.1111/jcpe.12750
Chan, D., Pelekos, G., Ho, D., Cortellini, P., & Tonetti, M. S. (2019). The
depth of the implant mucosal tunnel modifies the development and
resolution of experimental peri-­implant mucositis: A case-­control
study. Journal of Clinical Periodontology, 46(2), 248–­255. https://doi.
org/10.1111/jcpe.13066
Chang, M., Wennström, J. L., Odman, P., & Andersson, B. (1999).
Implant supported single-­tooth replacements compared to
contralateral natural teeth. Crown and soft tissue dimensions.
Clinical Oral Implants Research, 10(3), 185–­194. https://doi.
org/10.1034/j.1600-­0501.1999.100301.x
De Rouck, T., Eghbali, R., Collys, K., De Bruyn, H., & Cosyn, J. (2009). The
gingival biotype revisited: Transparency of the periodontal probe
through the gingival margin as a method to discriminate thin from
thick gingiva. Journal of Clinical Periodontology, 36(5), 428–­433.
https://doi.org/10.1111/j.1600-­051X.2009.01398.x
Frizzera, F., de Freitas, R. M., Muñoz-­Chávez, O. F., Cabral, G., Shibli, J.
A., & Marcantonio, E. (2019). Impact of soft tissue grafts to reduce
peri-­implant alterations after immediate implant placement and
Provisionalization in compromised sockets. The International Journal
of Periodontics & Restorative Dentistry, 39(3), 381–­389. https://doi.
org/10.11607/​prd.3224
Fürhauser, R., Florescu, D., Benesch, T., Haas, R., Mailath, G., & Watzek,
G. (2005). Evaluation of soft tissue around single-­tooth implant
crowns: The pink esthetic score. Clinical Oral Implants Research, 16(6),
639–­6 44. https://doi.org/10.1111/j.1600-­0501.2005.01193.x
Garabetyan, J., Malet, J., Kerner, S., Detzen, L., Carra, M. C., & Bouchard,
P. (2019). The relationship between dental implant papilla and den-
tal implant mucosa around single-­tooth implant in the esthetic area:
A retrospective study. Clinical Oral Implants Research, 30(12), 1229–­
1237. https://doi.org/10.1111/clr.13536
Hosseini, M., Worsaae, N., & Gotfredsen, K. (2020). Tissue changes at
implant sites in the anterior maxilla with and without connective
tissue grafting: A five-­year prospective study. Clinical Oral Implants
Research, 31(1), 18–­28. https://doi.org/10.1111/clr.13540
Hutton, C. G., Johnson, G. K., Barwacz, C. A., Allareddy, V., & Avila-­Ortiz,
G. (2018). Comparison of two different surgical approaches to in-
crease peri-­implant mucosal thickness: A randomized controlled
|
      107
clinical trial. Journal of Periodontology, 89(7), 807–­814. https://doi.
org/10.1002/JPER.17-­0597
Jemt, T. (1999). Restoring the gingival contour by means of provisional
resin crowns after single-­implant treatment. The International
Journal of Periodontics & Restorative Dentistry, 19(1), 20–­29.
Jiang, X., Di, P., Ren, S., Zhang, Y., & Lin, Y. (2020). Hard and soft tissue al-
terations during the healing stage of immediate implant placement
and provisionalization with or without connective tissue graft: A
randomized clinical trial. Journal of Clinical Periodontology, 47(8),
1006–­1015. https://doi.org/10.1111/jcpe.13331
Jung, R. E., Holderegger, C., Sailer, I., Khraisat, A., Suter, A., & Hämmerle,
C. H. (2008). The effect of all-­ceramic and porcelain-­fused-­to-­metal
restorations on marginal peri-­implant soft tissue color: A random-
ized controlled clinical trial. The International Journal of Periodontics
& Restorative Dentistry, 28(4), 357–­365.
Jung, R. E., Sailer, I., Hämmerle, C. H., Attin, T., & Schmidlin, P. (2007).
In vitro color changes of soft tissues caused by restorative materi-
als. The International Journal of Periodontics & Restorative Dentistry,
27(3), 251–­257.
Kamal, M., Elbattawy, W., Eiid, S. B., & Shoeib, M. (2020). Clinical
evaluation of platelet rich fibrin versus subepithelial connec-
tive tissue graft, for soft tissue augmentation around implant in
the aesthetic zone: A randomized control clinical trial. Egyptian
Dental Journal, 66, 2187–­2195. https://doi.org/10.21608/​
edj.2020.42015.1249
Kan, J. Y., Rungcharassaeng, K., Lozada, J. L., & Zimmerman, G. (2011).
Facial gingival tissue stability following immediate placement and
provisionalization of maxillary anterior single implants: A 2-­ to
8-­year follow-­up. The International Journal of Oral & Maxillofacial
Implants, 26(1), 179–­187.
Kan, J. Y., Rungcharassaeng, K., Umezu, K., & Kois, J. C. (2003).
Dimensions of peri-­implant mucosa: An evaluation of maxillary
anterior single implants in humans. Journal of Periodontology, 74(4),
557–­562. https://doi.org/10.1902/jop.2003.74.4.557
Langer, B., & Calagna, L. (1980). The subepithelial connective tissue
graft. The Journal of Prosthetic Dentistry, 44(4), 363–­367. https://
doi.org/10.1016/0022-­3913(80)90090​-­6
Lin, C. Y., Chen, Z., Pan, W. L., & Wang, H. L. (2018). Impact of timing
on soft tissue augmentation during implant treatment: A system-
atic review and meta-­analysis. Clinical Oral Implants Research, 29(5),
508–­521. https://doi.org/10.1111/clr.13148
Lops, D., Stellini, E., Sbricoli, L., Cea, N., Romeo, E., & Bressan, E. (2017).
Influence of abutment material on peri-­implant soft tissues in an-
terior areas with thin gingival biotype: A multicentric prospective
study. Clinical Oral Implants Research, 28(10), 1263–­1268. https://
doi.org/10.1111/clr.12952
Mailoa, J., Arnett, M., Chan, H. L., George, F. M., Kaigler, D., & Wang,
H. L. (2018). The association between buccal mucosa thickness
and Periimplant bone loss and attachment loss: A cross-­sectional
study. Implant Dentistry, 27(5), 575–­581. https://doi.org/10.1097/
ID.00000​0 0000​0 00803
Migliorati, M., Amorfini, L., Signori, A., Biavati, A. S., & Benedicenti, S.
(2015). Clinical and aesthetic outcome with post-­extractive im-
plants with or without soft tissue augmentation: A 2-­year random-
ized clinical trial. Clinical Implant Dentistry and Related Research,
17(5), 983–­995. https://doi.org/10.1111/cid.12194
Müller, H. P., Heinecke, A., Schaller, N., & Eger, T. (2000). Masticatory
mucosa in subjects with different periodontal phenotypes. Journal
of Clinical Periodontology, 27(9), 621–­626. https://doi.org/10.1034/
j.1600-­051x.2000.02700​9621.x
Papapetros, D., Karagiannis, V., Konstantinidis, A., & Apatzidou, D. A.
(2019). Interim tissue changes following connective tissue graft-
ing and two-­stage implant placement. A randomized clinical trial.
Journal of Clinical Periodontology, 46(9), 958–­968. https://doi.
org/10.1111/jcpe.13159
 |
108      JUNG et al.
Puzio, M., Błaszczyszyn, A., Hadzik, J., & Dominiak, M. (2018). Ultrasound
assessment of soft tissue augmentation around implants in the aes-
thetic zone using a connective tissue graft and xenogeneic collagen
matrix -­1-­year randomised follow-­up. Annals of Anatomy, 217, 129–­
141. https://doi.org/10.1016/j.aanat.2017.11.003
Romeo, E., Lops, D., Rossi, A., Storelli, S., Rozza, R., & Chiapasco, M.
(2008). Surgical and prosthetic management of interproximal region
with single-­implant restorations: 1-­year prospective study. Journal
of Periodontology, 79(6), 1048–­1055. https://doi.org/10.1902/
jop.2008.070431
Sala, L., Bascones-­Martínez, A., & Carrillo-­de-­Albornoz, A. (2017).
Impact of abutment material on peri-­implant soft tissue color. An
in vitro study. Clinical Oral Investigations, 21(7), 2221–­2233. https://
doi.org/10.1007/s0078​4-­016-­2015-­9
Schmitt, C. M., Brückbauer, P., Schlegel, K. A., Buchbender, M., Adler, W.,
& Matta, R. E. (2021). Volumetric soft tissue alterations in the early
healing phase after peri-­implant soft tissue contour augmentation
with a porcine collagen matrix versus the autologous connective tis-
sue graft: A controlled clinical trial. Journal of Clinical Periodontology,
48(1), 145–­162. https://doi.org/10.1111/jcpe.13387
Schneider, D., Grunder, U., Ender, A., Hämmerle, C. H., & Jung, R. E.
(2011). Volume gain and stability of peri-­implant tissue following
bone and soft tissue augmentation: 1-­year results from a prospec-
tive cohort study. Clinical Oral Implants Research, 22(1), 28–­37.
https://doi.org/10.1111/j.1600-­0501.2010.01987.x
Schwarz, F., Alcoforado, G., Guerrero, A., Jönsson, D., Klinge, B., Lang,
N., Mattheos N., Mertens B., Pitta J., Ramanauskaite A., Sayardoust
S., Sanz-­Martin I., Stavropoulos A. Heitz-­Mayfield, L. (2021). Peri-­
implantitis: Summary and consensus statements of group 3. The 6th
EAO consensus conference 2021. Clinical Oral Implants Research,
32(Suppl. 21), 245–­253. doi:https://doi.org/10.1111/clr.13827
Tatum, C. L., Saltz, A. E., Prihoda, T. J., DeGroot, B. S., Mealey, B. L.,
Mills, M. P., & Huynh-­Ba, G. (2020). Management of Thick and
Thin Periodontal Phenotypes for immediate dental implants in the
esthetic zone: A controlled clinical trial. The International Journal
of Periodontics & Restorative Dentistry, 40(1), 51–­59. https://doi.
org/10.11607/​prd.4317
Thoma, D. S., Gasser, T. J. W., Jung, R. E., & Hämmerle, C. H. F. (2020).
Randomized controlled clinical trial comparing implant sites aug-
mented with a volume-­stable collagen matrix or an autogenous
connective tissue graft: 3-­year data after insertion of reconstruc-
tions. Journal of Clinical Periodontology, 47(5), 630–­639. https://doi.
org/10.1111/jcpe.13271
Thoma, D. S., Zeltner, M., Hilbe, M., Hämmerle, C. H., Hüsler, J., & Jung,
R. E. (2016). Randomized controlled clinical study evaluating effec-
tiveness and safety of a volume-­stable collagen matrix compared to
autogenous connective tissue grafts for soft tissue augmentation
at implant sites. Journal of Clinical Periodontology, 43(10), 874–­885.
https://doi.org/10.1111/jcpe.12588
Ustaoğlu, G., Paksoy, T., & Gümüş, K. (2020). Titanium-­prepared platelet-­
rich fibrin versus connective tissue graft on peri-­implant soft tissue
thickening and keratinized mucosa width: A randomized, controlled
trial. Journal of Oral and Maxillofacial Surgery, 78(7), 1112–­1123.
https://doi.org/10.1016/j.joms.2020.02.019
Valles, C., Vilarrasa, J., Barallat, L., Pascual, A., & Nart, J. (2022). Efficacy
of soft tissue augmentation procedures on tissue thickening around
dental implants: A systematic review and meta-­analysis. Clinical
Oral Implants Research, 33(S23), 72–­99. https://doi.org/10.1111/
clr.13920
van Nimwegen, W. G., Raghoebar, G. M., Zuiderveld, E. G., Jung, R. E.,
Meijer, H. J. A., & Mühlemann, S. (2018). Immediate placement and
provisionalization of implants in the aesthetic zone with or without
a connective tissue graft: A 1-­year randomized controlled trial and
volumetric study. Clinical Oral Implants Research, 29(7), 671–­678.
https://doi.org/10.1111/clr.13258
Wiesner, G., Esposito, M., Worthington, H., & Schlee, M. (2010).
Connective tissue grafts for thickening peri-­implant tissues at
implant placement. One-­year results from an explanatory split-­
mouth randomised controlled clinical trial. European Journal of Oral
Implantology, 3(1), 27–­35.
How to cite this article: Jung, R. E., Becker, K., Bienz, S. P.,
Dahlin, C., Donos, N., Hammächer, C., Iglhaut, G., Liñares, A.,
Ortiz-­Vigón, A., Sanchez, N., Sanz-­Sánchez, I., Thoma, D. S.,
Valles, C., Weng, D., & Nart, J. (2022). Effect of peri-­implant
mucosal thickness on esthetic outcomes and the efficacy of
soft tissue augmentation procedures: Consensus report of
group 2 of the SEPA/DGI/OF workshop. Clinical Oral Implants
Research, 33(Suppl. 23), 100–­108. https://doi.org/10.1111/
clr.13955